Abstract: Two employees were involved in setting up "slap" or "spanker" dies in a Toledo 350-ton, part-revolution, mechanical power press. The first worker was arranging the dies and adjusting the depth of the die stroke by placing shims between the top of the "slap" dies and the press ram. A coworker was operating the press controls. Two dies were set up and the third was in the process of being set up. The first worker had placed several sheet metal shims on top of the die and the operator cycled the press but the die stroke depth was not enough to punch a hole in the part. The first worker then added a metal block to the top of the shims. The operator cycled the press again. The press was in inch mode; however, the operator did not inch the press down, he held the buttons in and cycled the press. The last metal block apparently added too much shim, which caused the die to bottom out. At this point the shims, metal block and broken parts of the die were expelled out the front of the press. Employee #1, who had walked up to ask the first worker a question, was struck in the throat area by flying parts and later died from these injuries. Employee #2, who was walking by, was also struck by flying parts and received contusions.